MEDICARE: IA Y KUE D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101015717	MI
2	207Q00000X	Family Medicine Physician	95143	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45-1674932	OTHER	MI	COMMERCIAL FEIN
2	700H273300	OTHER	MI	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1902883143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IA Y KUE D.O.

Provider Business Mailing Address
First Line	:	115 LEE BYRD RD
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-2310
Country	:	US
Telephone Number	:	707-554-4717
Fax Number	:	770-554-4681

Provider Business Practice Location Address
First Line	:	115 LEE BYRD RD
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-2310
Country	:	US
Telephone Number	:	707-554-4717
Fax Number	:	770-554-4681

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	01/11/2024

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Directions to “ IA Y KUE D.O.” Practice Location

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